LLS Upper Plains Honored Hero Information

By completing this application, you are signging up to receive more information about the LLS Honored Hero Program and agree to release certain information regarding your diagnosis and cancer journey. Once signed up to be an Honored Hero, the LLS Upper Plains Region will share certain information with LLS Sponsors and staff to amplify the voice of our mission.

First Name (of Patient) *

Last Name (of Patient) *

Guardian First Name (if Survivor is a minor)

Last Name (if Survivor is a minor)

Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

DOB *

School Name (if applicable)

2023-2024 Grade Level (if applicable)

Favorite Activities

Siblings/Spouse/Family Member Names and Ages

T-Shirt Size *

Diagnosis

Date of Diagnosis *

Type of Diagnosis *

Please provide a description of your journey through treatment: *

Treatments, Past and Current (i.e. specific chemotherapy, remission date, etc) *

Please write a brief description of your current interests/hobbies and/or a fun fact about yourself to share on our Honored Hero Poster. (3-4sentences) *

How has LLS helped you and your family? *

What would you like to say to donors, staff, and sponsors raising funds for patients with blood cancer? *

Photographs

Please upload up to three photographs, including one photo that would serve well as a headshot.

Picture (1)

Provide a caption (Optional)

Picture (2)

Provide a caption (Optional)

Picture (3)

Provide a caption (Optional)

Level of Involvement

I am willing to: *

Please list any other ways you would like to be involved: